Sternberg came up with an ethical decision making model which would allow for someone to walk through steps which would help them to make a sound ethical decision. This model consists of being able to recognize that there is an event to which to react, define the event as having an ethical dimension, decide that the ethical dimension is of sufficient significance to merit an ethics-guided response, take responsibility for generating an ethical solution to the problem, figure out what abstract ethical rule(s) might apply to the problem, decide how these abstract ethical rules actually apply to the problem so as to suggest a concrete solution, prepare for possible repercussions of having acted in what one considers an ethical manner, act (Sternberg, 2012).
In using this model of decision making, the nurse practitioner would first determine that there is an event in which to react to. This event would be the doctor asking her to sign the papers which would help to determine the status of the patient wishing to receive benefits of Physician Assisted Suicide. The doctor should be aware of the rules regarding this situation and should not be pushing the nurse to do what the doctor wants done. Following these steps the nurse would have to determine the ethical dimensions of the event. The nurse practitioner would have to determine the weight of these ethical values and determine whether or not they are significant to her decision. The nurse would then try and determine a course of action in deciding upon an ethical solution. Find reasoning to back up her solution. Then the nurse would have to decide a course of action and then act upon her decision.
Sternberg, R. J. (2012). A model for ethical reasoning. Review of General Psychology, 16(4), 319-326. doi: 10.1037/a0027854
Tuesday, November 5, 2013
Friday, November 1, 2013
Introduction
Health care workers are faced with many situations in which they
might now know what the right thing to do is. This is especially true for
nurses. Nurses work with the patients on a closer level than anyone else in the
medical field. They are the ones which will face many situations which they
will have to allow for legal and ethical laws to take over. They can better be
able to handle these situations through completing legal and ethical reasoning.
Reasoning the law and reasoning ethically can help the nurse better care for
the client, as well as stay within their rights and scope of practice.
Case Study
Ms. Woods is a recently graduated nurse practitioner. She works in the state of Oregon, in a small town. Ms. Woods works with the only physician in the town, while the other closest physician works forty-five minutes away. Ms. Woods cares for Mr. Delmar who is a sixty year old man, recently diagnosed with aggressive stage IV lung cancer. Mr. Delmar has a life expectancy less than six months. Mr. Delmar has put in his two verbal and one written request for a drug from the physician to be able to end his life and has also informed his next of kin about the decision to end his life (Lachman, 2010). However, with another physician working forty-five minutes away, Mr. Delmar has not reached out to get the needed signature of a second physician (Lachman, 2010). The physician that Ms. Woods is working under asks for her to step in and provide the opinion and signature needed for Mr. Delmar to receive the medication he is seeking. Ms. Woods is unsure of her role in the situation however, she respects the professionalism of the physician and trusts that the physician will not ask of her what is outside of her scope of practice. Ms. Woods also believes in the sanctity of beneficence and believes that the best thing for the patient is for them to be able to die with dignity. With this in mind, Ms. Woods proceeds on with the second opinion and brings forth the necessary documents needed to fulfill the request made by Mr. Delmar.
Ethical Considerations
Mr. Delmar is choosing to make a
decision about his choice of health care. In this way, he is choosing to
take charge of the situation to ensure that he has a say-so in the kind of care
he is to receive. Ms. Woods, the nurse practitioner, believes that
all patients should be able to act autonomously. She feels that by signing
the necessary documents and acting as his second opinion, that she is able
to fulfill his right to autonomy.
However, the bigger issue in this
scenario is the practice of beneficence that is an ethical principle which
all nurses should follow. Beneficence is the principle of doing good for the
client. Ms. Woods may believe that the best course of action for the
client is to act as a consult on the case so that he may choose to end his
life. However, in acting on this kind of thinking the nurse may instead hinder
the care of the patient. The physician acting as a secondary opinion will most
likely be able to have a better idea of the patients disease process for the
patient and would be able to make a better decision for care of the client.
They may be able to provide better forms of palliative care and other services
which the nurse cannot provide.
Ethical Reasoning
End of life care promotes many
ethical issues in all healthcare workers. Physicians, nurses, social workers,
etc. have to be able to decide where they stand on certain issues to be able to
protect the patient as well as themselves. Nurses, especially, have to look at
what they believe and what they think should happen in end of life care because
they are the ones which work closest with the patient.
Ethical reasoning
seeks truth, fosters ethical decision making, and leads to ethical nursing
practice (Callister, Luthy, Thompson, & Memmott, 2009). Ms. Woods believes
that Mr. Delmar has the right to physician assisted suicide and wishes to help
him because she believes in the ethical principle of autonomy. Ms. Woods
believes that the patient should be able to make his own decisions regarding
his end of life care and that he should be able to have all resources available
to him to make this happen.
Pseudo-ethics deal
with the ethical decisions which might be twisted to fit the situation. Pseudo-ethics in this situation works with the ethical reasoning of beneficence. In one sense Ms. Woods thinks she is caring properly for the patient, by following his wishes and allowing him to die with dignity. However, Ms. Woods may not be able to fully consider all the aspects of Mr. Delmar's illness and may in fact make mistakes in providing a second opinion for this patient.
Ethical reasoning
has some elements which provide a guideline for the health care worker to
follow. These steps include recognizing that there is an event to which to
react, defining the event as having an ethical dimension, deciding that the
ethical dimension is of sufficient significance to merit an ethics-guided
response, taking responsibility for generating an ethical solution to the
problem, figuring out what abstract ethical rule(s) might apply to the problem,
deciding how these abstract ethical rules actually apply to the problem so as
to suggest a concrete solution, preparing for possible repercussions of having
acted in what one considers an ethical manner, and acting (Sternberg, 2012). In
this case Ms. Woods knows that the event is the notion of physician assisted
suicide for her patient. Ms. Woods believe that the ethical principle of
autonomy fits well for Mr. Delmar and the care he should receive. Ms. Woods
will then have to decide if autonomy for a patient outweighs her regard for the
law. If Ms. Woods decides to go against the law and sign as a consult on the
case, she will have to face the ethical principles of what autonomy means and
how far she will go to protect it, and will then have to face the consequences
of her decision.
The logic of
ethical reasoning helps to be able to tie all of the information together. It
can help to define what the nurse feels versus what is right. It also can help
to define what ethical principles are able to withstand a specific situation.
It can help the nurse to make a proper ethical decision, without going on gut
instinct. It can provide information on how other areas of care were handled
and how each ethical principle helped to solve the problems faced.
Ethical reasoning
has both advantages and disadvantages. The disadvantages of ethical reasoning
pertain to the nurse and having to reevaluate their essence of care. The nurse
may feel as though certain things should be done and ethical reasoning may
point out to them that it is not right. The nurse may also have a conflict of
interest in regards to the reasoning being implicated in a case. Although some
disadvantages do exist, some advantages exist as well. The nurse who is
undergoing ethical reasoning may find that they are not in alignment with what
the proper usage of ethical principles includes. The nurse then can align
themselves to what the principle mandates as proper care, and in the end can
better care for the patient. Another advantage is that the nurse will have the
ability to learn what other nurses do in the same situations. This can help to
better the continuity of care across the nursing field in all areas.
Legal Considerations
When working
with Mr. Delmar; Ms. Woods must first know what the law states about nurse
practitioners involvement within the Death with Dignity Act of Oregon. It is
not enough for Ms. Woods to go off of what is told to her by the physician that
she is working under. Ms. Woods must also set aside her beliefs about what
should happen with Mr. Delmar to be able to look at the law fully and
comprehensively.
Legal Reasoning
End of life care brings with it
many obstacles that healthcare workers will have to face when working with
their patients. One way for the healthcare worker to ensure that they are
staying within the legal boundaries of what is happening, is by looking at
legal reasoning. Legal reasoning focuses on how people develop a sense of legal
consciousness and evaluate the appropriateness of formal, codified rules in
society (Cohn, Bucolo, Rebellon, & Van Gundy, 2010). Legal reasoning helps
people to distinguish between what is right within society versus what they
think they should do. It can help them to make those decisions where they may
want to act in one way, but could instead find themselves making the wrong
decisions.
Legal
interpretation in this case study is based upon the interpretation of who is
and who is not considered a healthcare employee who can sign the necessary
papers for a second opinion. The Oregon Death with Dignity Act allows for the
fact that the attending physician may feel more comfortable collaborating in
the overall care of a patient with a colleague who is willing to provide the
prescription under the Oregon Act (The Task Force to Improve the Care of
Terminally-Ill Oregonians, “Physicians”, 2008). Interpretation of this law
comes in the fact of who the attending physician considers to be someone who
can has prescriptive authority within the state of Oregon.
Coherence for the
law comes from being able to know exactly what the law states. Though Ms. Woods
as a nurse practitioner in Oregon does have prescriptive authority, she is not
allowed to act as a consult for this case. The Oregon Death with Dignity Act
does not allow nurse practitioners, even those with prescriptive authority to
serve as the attending or consulting physician (The Task Force to Improve the
Care of Terminally-Ill Oregonians, “Other Professionals”, 2008).
The
logic in legal reasoning stems from the being able to see clearly what the law
is and how the law works. The rule of law requires that similar cases should be
decided similarly, that each case should be decided on its merits, and that
decision-making processes should comply with applicable rules of procedure and
evidence (Walker, 2012). This case may not provide any kinds of studies of
other cases connecting the nurse practitioner to physician assisted suicide.
The law is cut and dry about the role of the nurse practitioner and what they
may or may not be able to do. Ms. Woods however, may be able to look at other
situations where ethical reasoning comes into play regarding end of life
decisions and how the nurse is able to help the patient with their own decision
making. Case law could be used in this case to be able to help Ms. Woods know
the legal actions that are taken against nurse practitioners who are involved
in performing restricted acts regarding physician assisted suicide.
Legal
analysis is done when all of the pieces of legal reasoning are put together.
For this case study legal interpretation says that the attending physician may
want to collaborate with a colleague who has prescriptive authority. However,
when we look further into the law and are able to understand what it says, we
find out that the nurse practitioner who has prescriptive authority is not
allowed to act as a consult for the case. Case studies and case laws for
physician assisted suicide may only offer little insight into the ethical
reasoning of how to help a patient or what action has been taken in the past by
other nurse practitioners. Analysis should prove to Ms. Woods that she may not
act as she wishes in regards to the patient care provisions in physician
assisted suicide.
Ethical and Legal Solution
Ethical and legal solutions may not always seem like the easiest
decisions to make. However, as medical professionals we have a responsibility
to keep the patient safe. Ethical and legal safeguards are put into place so
that we can make sure that these things happen; whether we agree with the
reasoning behind the solution or not.
Ms. Woods could
have handled this situation in many different ways. She could have looked into
the laws and regulations of the scope of practice for a nurse in Oregon; while
also looking up what the law on Physician Assisted Suicide stated. She could have looked into the
ethical principles for nursing and known which ones she would have been in
violation of wrong-doing. While we may think we know what is best for the
patient, and while we may agree that the patient has the ultimate choice; there
are times when we don’t have the option to choose. In this case, Ms. Woods
should not have relied solely upon the physician whom she was working with, she
should have done research on the topic herself, and she herself should have
gotten a second opinion on what she should have done.
Conclusion
The nurse is faced
with many decisions that they will not know what to do in. The nurse has to
deal with the orders of the doctors, the decisions of the patient, and the
legal system in which we live. These obstacles in the nurse’s job may not
always be pleasant to deal with; but the nurse must always know how to handle
the situation in the proper manner. The nurse has to be responsible to their
self and must know the ethical and legal dilemmas they enter into when facing
an unknown situation. By doing these things, the nurse can stay protected while
also ensuring that the right thing is being done.
References
Amaya,
Amalia. (2010). Legal justification by optimal coherence. Ratio Juris, 24(3), 304-329. doi: 10.1111/j.1467-9337.2011.00486.x
Callister, L. C., Luthy, K. E., Thompson, P., &
Memmott, R. J. (2009). Ethical reasoning in baccalaureate nursing students. Nursing Ethics, 16(4), 499-510. doi: http://dx.doi.org/10.1177/0969733009104612
Cohn,
E. S., Bucolo, D., Rebellon, C. J. & Van Gundy, K. (2010). An integrated
model of legal and moral reasoning and rule-violating behavior: The role of
legal attitudes. Law & Human Behavior
(Springer Science & Business Media B.V.), 34(4), 295-309. doi: 10.1007/s10979-009-9185-9
Lachman, V. D. (2010). Physician-assisted suicide:
compassionate liberation or murder? MEDSURG
Nursing, 19(2), 121-5.
Sternberg, R. J. (2012). A model for ethical
reasoning. Review of General Psychology,
16(4), 319-326. doi: 10.1037/a0027854
The
Task Force to Improve the Care of Terminally-Ill Oregonians. (2008). Attending
Physician and Consulting Physician. The
Oregon Death with Dignity Act: A Guidebook for Health Care Professionals. Retrieved
from http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf
The
Task Force to Improve the Care of Terminally-Ill Oregonians. (2008). The Role
of Other Health Care Professionals. The
Oregon Death with Dignity Act: A Guidebook for Health Care Professionals. Retrieved
from http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf
Walker, V. R. (2012). Discovering the logic of legal
reasoning. Retrieved from http://law.hofstra.edu/pdf/Academics/Journals/LawReview/lrv_issues_v35n04_BB2_Walker_35_4_final.pdf
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